Additional Benefits

You have the option to purchase accident insurance, which helps to protect your finances after an accident. You are paid a lump sum if you have a covered injury and can use the money to help pay out-of-pocket medical costs or everyday expenses.

Catastrophic Insurance Amount
Employee	$25,000
Spouse	$10,000
Child	$5,000

Benefits	Amount or Surgical	Timeframe or Non-Surgical
Emergency Care Benefits	Amount	Timeframe
Ambulance - Air	$1,500	72 hours
Ambulance - Ground	$300	72 hours
Emergency Room Visit	$200	72 hours
Urgent Care	$125	72 hours
Initial Care Visit (not payable if Urgent Care or ER visit benefit is payable)	$100	30 days
Emergency Dental Care - Crown	$300	30 days
Emergency Dental Care - Extraction	$100	30 days
Outpatient X-ray	$75	90 days
Major Diagnostic Exam (such as CT scan, MRI, EEG)	$300	90 days
Brain Injury Diagnosis	$200	30 days
Specific Injury Benefits	Amount	Timeframe
Burns	up to $25,000	72 hours
Lacerations	up to $800	72 hours
Skin Graft	25% of burn benefit	72 hours
Dislocations	Surgical	Non-Surgical
Lower jaw (Temporomandibular)	$1,800	$900
Shoulder (Glenohumeral)	$1,800	$900
Collarbone and breastbone (Sternoclavicular)	$1,800	$900
Elbow	$1,800	$900
Wrist (Radiocarpal and/or intercarpal)	$1,800	$900
Hand (Carpometacarpal and/or intrametacarpal)	$1,800	$900
Fingers (Interphalangeal and/or metacarpophalangeal)	$450	$225
Hip	$9,000	$4,500
Kneecap (Patella)	$4,500	$2,250
Ankle (Talocalcaneal and/or talocalcaneonavicular	$2,700	$1,350
Foot (Tarsometatarsal and/or intermetatarsal)	$2,700	$1,350
Toes (Interphalangeal and/or metatarsalphalangeal)	$450	$225
Fractures	Surgical	Non-Surgical
Skull, depressed (Cranial bones)	$6,000	$3,000
Skull, non-depressed (Cranial bones)	$3,000	$1,500
Bones of face (Except nose and lower jaw)	$1,200	$600
Nose (Nasal bones)	$900	$450
Lower jaw (Mandible)	$1,200	$600
Shoulder blade (Scapula)	$1,200	$600
Collarbone (Clavicle)	$900	$450
Breastbone (Sternum)	$1,200	$600
Rib	$900	$450
Upper arm (Humerus)	$1,200	$600
Forearm (Radius and/or ulna)	$1,200	$600
Wrist (Carpals)	$1,200	$600
Hand (Metacarpals, except fingers)	$1,200	$600
Fingers (Phalanges)	$400	$200
Vertebral body (Except vertebral processes)	$3,000	$1,500
Vertebral process	$1,200	$600
Tail bone (Coccyx)	$900	$450
Pelvis (Except tail bone and hip bones)	$3,000	$1,500
Hip bones (Illium, ischium and/or pubis)	$6,000	$3,000
Thigh (Femur)	$3,000	$1,500
Knee cap (Patella)	$1,200	$600
Lower leg (Tibia and/or fibia)	$3,000	$1,500
Ankle (Talus)	$1,200	$600
Foot (Metatarsals and calcaneus, except toes)	$1,200	$600
Toes (Phalanges)	$400	$200
Follow-up care benefits	Amount	Timeframe
Physician Follow-Up Office Visit	$75	365 days
Therapy Services	$25	365 days
Medical Device	$100	365 days
Prosthetic Device(s)	$750	365 days
Hospital	Amount	Timeframe
Admission	$1,500	Begins within 90 days
Daily Confinement	$300	Begins within 90 days
ICU Confinement	$600	Begins within 30 days
Rehab facility confinement	$150	Begins within 365 days
Surgical	Amount	Timeframe
Exploratory/Arthroscopic	$200	365 days
Abdominal/Cranial/Thoracic	$2,000	365 days
Herniated Disc	$900	365 days
Torn Knee Cartilage	$750	365 days
Ligament/Rotator Cuff/Tendon	$750	365 days
Eye Procedure	$400	90 days
Blood Products	$450	90 days
Pain Management	$150	90 days
Transportation per trip	$300	365 days
Lodging per night	$125	365 days
Childcare per day	$20	365 days
Health Screening	$50	N/A
Accidental Death	Amount	Timeframe
Basic Accidental Death	100%	365 days
Common Carrier Accidental Death	300%	365 days
Transportation of Remains	Up to $5,000	365 days
Dismemberment & Paralysis	Amount	Timeframe
Loss of both hands, loss of both feet, loss of entire sight of both eyes or any combination of two or more of these losses	100%	365 days
Loss of Speech and Loss of Hearing (Both ears)	100%	365 days
Loss of One Hand, Loss of One Foot, Loss of Entire Sight of One Eye or Loss of Hearing (Both ears)	50%	365 days
Loss of Thumb and Index Finger of the Same Hand	25%	365 days
Loss of Multiple Fingers or Loss of Multiple Toes	0%	365 days
Quadriplegia (Paralysis of both upper and both lower limbs)	100%	365 days
Triplegia (Paralysis of three limbs)	75%	365 days
Hemiplegia (Paralysis of an upper and a lower limb)	50%	365 days
Paraplegia (Paralysis of both lower limbs)	50%	365 days
Uniplegia (Paralysis of a limb)	25%	365 days
Other Benefits	Amount	Timeframe
Reasonable Modifications	Up to 10%	365 days
Coma	50%	365 days

	Per Pay Period Cost
Employee Only	$7.07
Employee + Spouse	$9.38
Employee + Children	$12.02
Employee + Family	$14.34

Downloads

Summary of Benefits

You have the option to purchase critical illness insurance, which provides a fixed, lump-sum benefit upon the diagnosis of a serious illness like heart attack, stroke, or cancer. Benefits are paid directly to you and may be used for any reason from deductibles and prescriptions to travel expenses, childcare or other everyday expenses.

	Benefits
Heart/Circulatory/Motor Function Category
Heart Attack (Myocardial Infarction)	100% of the CI Principal Sum
Heart Transplant/Placement on UNOS List	100% of the CI Principal Sum
Heart Valve Surgery	25% of the CI Principal Sum
Coronary Artery Bypass	25% of the CI Principal Sum
Aortic Surgery	25% of the CI Principal Sum
Stroke	100% of the CI Principal Sum
ALS (Lou Gehrig’s) Disease*	100% of the CI Principal Sum
Advanced Alzheimer’s Disease*	100% of the CI Principal Sum
Advanced Parkinson’s Disease*	100% of the CI Principal Sum
Organ Category
Major Organ Transplant/Placement on UNOS List	100% of the CI Principal Sum
End Stage Renal Failure	100% of the CI Principal Sum
Acute Respiratory Distress Syndrome (ARDS)	25% of the CI Principal Sum
Childhood/Developmental Category
Cerebral Palsy*	100% of the CI Principal Sum
Structural Congenital Defects*	100% of the CI Principal Sum
Genetic Disorders*	100% of the CI Principal Sum
Congenital Metabolic Disorders*	100% of the CI Principal Sum
Type 1 Diabetes*	100% of the CI Principal Sum
Cancer Category
Cancer (Invasive)	100% of the CI Principal Sum
Bone Marrow Transplant	50% of the CI Principal Sum
Carcinoma in Situ (Non-Invasive Cancer)	25% of the CI Principal Sum
Benign Brain Tumor	25% of the CI Principal Sum

	Monthly EMPLOYEE/SPOUSE Rates by Age per $1,000 of Benefit
Age	Tobacco
<30	$0.29
30-39	$0.54
40-49	$1.25
50-59	$2.83
60-69	$6.12
70-79	$11.52
80+	$15.68

	CHILD
Dependent Age Limit	26
Child Benefit	25% of employee election
Guarantee Issue
Employee	$20,000
Spouse	$20,000 or equal to employee election
Child	$5,000 or 25% of employee election

Downloads

Summary of Benefits

You have the option to purchase hospital indemnity insurance, which pays you benefits while you are confined to a hospital. This type of coverage is helpful because it covers your out-of-pocket expenses not covered by your medical plan.

	Benefits
Hospital Admission	$1,000
Daily Hospital Confinement	$100
ICU Admission	$2,000
Daily ICU Confinement	$200
Daily Newborn Nursery Care Confinement	$75
Additional Benefits
Express Benefit	Equal to 1 times the Hospital Confinement benefit
Health Screening Benefit	$50

	Per Pay Period Cost
Employee Only	$6.98
Employee + Spouse	$16.06
Employee + Children	$9.64
Employee + Family	$19.27

Downloads

Summary of Benefits

Group Number

G000C2KW

Provided By

Mutual of Omaha

Provider Website

https://www.mutualofomaha.com/

Customer Service

800.655.5142